Chapter 3Infectious Diseases Related To Travel
Aron J. Hall, Ben Lopman
Norovirus infection is caused by nonenveloped, single-stranded RNA viruses of the genus Norovirus, which have also been referred to as “Norwalk-like viruses,” Norwalk viruses, and small round-structured viruses. Norovirus gastroenteritis is sometimes incorrectly referred to as “stomach flu”; however, there is no biologic association with influenza or influenza viruses.
Transmission occurs primarily through the fecal-oral route, either through direct person-to-person contact or indirectly via contaminated food or water. Norovirus is also indirectly spread through aerosols of vomitus and contaminated environmental surfaces and objects.
Seroprevalence studies in the Amazon, southern Africa, Mexico, Chile, and Canada have shown that norovirus infections are common throughout the world, and most children will have experienced ≥1 infection by the age of 5 years. Norovirus infections can occur year round, but in temperate climates, norovirus activity peaks during the winter. In the United States, norovirus is the leading cause of sporadic cases and outbreaks of gastroenteritis, estimated to cause 21 million illnesses a year and approximately 50% of all foodborne outbreaks. Noroviruses are common in both developing and developed countries.
Norovirus is a cause of travelers’ diarrhea; prevalence ranges from 3% to 17% of travelers returning with diarrhea. However, coinfection and asymptomatic infection with norovirus are common, so focused studies are needed to determine exactly how frequently norovirus is the cause of disease. Risk for infection is present anywhere food is prepared in an unsanitary manner and may become contaminated, or where drinking water is inadequately treated. Of particular risk are “ready-to-eat” cold foods, such as sandwiches and salads. Raw shellfish, especially oysters, are also a frequent source of infection, because virus from contaminated water concentrates in the gut of these filter feeders. Contaminated ice has also been implicated in outbreaks.
Large norovirus outbreaks are associated with settings where people live in close quarters and can easily infect each other, such as hotels, cruise ships, camps, and hospitals. Viral contamination of inanimate objects (fomites) may persist during outbreaks and be a source of infection. On cruise ships, for instance, such environmental contamination has caused recurrent norovirus outbreaks on successive cruises with newly boarded passengers. Transmission of norovirus on airplanes has been reported during both domestic and international flights and likely results from contamination of lavatories or from symptomatic passengers in the cabin.
Infected people usually have an acute onset of vomiting with nonbloody diarrhea. The incubation period is 12–48 hours. Other symptoms include abdominal cramps, nausea, and occasionally a low-grade fever. Illness is generally self-limited, and full recovery can be expected in 1–3 days. In some cases, dehydration, especially in patients who are very young or elderly, may require medical attention.
Norovirus infection is generally diagnosed based on symptoms. No laboratory tests have been approved by the Food and Drug Administration to guide clinical management of individual patients, but laboratory testing is used during outbreak investigations by public health agencies. Norovirus diagnostic testing is usually not available in developing countries.
The most common diagnostic test used at state public health laboratories and CDC is RT-PCR, which rapidly and reliably detects the virus in stool specimens. Several commercial EIAs are available to detect the virus in stool specimens. The specificity and sensitivity of these assays are poor compared with RT-PCR.
These tests have been used occasionally by cruise lines during outbreaks on ships.
Supportive care, especially oral or intravenous rehydration. Antimotility agents should be avoided in children aged <3 years, but may be a useful adjunct to rehydration in older children and adults. Antiemetic agents should generally be reserved for adults. Antibiotics are not useful in treating patients with norovirus disease.
No vaccine is currently available, although vaccine development efforts are advancing. Noroviruses are common and highly contagious, but the risk for infection can be minimized by frequent and proper handwashing and avoiding possibly contaminated food and water. Washing hands with soap and water for at least 20 seconds is considered the most effective way to reduce norovirus contamination; alcohol-based hand sanitizers (containing ≥60% alcohol) might be useful between handwashings but should not be considered a substitute for soap and water.
In addition to handwashing, measures to prevent transmission of noroviruses between people traveling together include carefully cleaning up fecal material or vomit and disinfecting contaminated surfaces and toilet areas. Products should be approved by the Environmental Protection Agency for norovirus disinfection; alternatively, a high concentration of domestic bleach (5–25 tablespoons bleach per gallon of water) may be used. Soiled articles of clothing should be washed at the maximum available cycle length and machine-dried at high heat.
To help prevent the spread of noroviruses, ill people have been isolated on cruise ships and in institutional settings.
CDC website: www.cdc.gov/norovirus
- Apelt N, Hartberger C, Campe H, Loscher T. The prevalence of norovirus in returning international travelers with diarrhea. BMC Infect Dis. 2010;10:131.
- Atmar RL, Bernstein DI, Harro CD, Al-Ibrahim MS, Chen WH, Ferreira J, et al. Norovirus vaccine against experimental human Norwalk virus illness. N Engl J Med. 2011 Dec 8;365(23):2178–87.
- Glass RI, Parashar UD, Estes MK. Norovirus gastroenteritis. N Engl J Med. 2009 Oct 29;361(18):1776–85.
- Hall AJ, Vinjé J, Lopman B, Park GW, Yen C, Gregoricus N, et al. Updated norovirus outbreak management and disease prevention guidelines. MMWR Recomm Rep. 2011 Mar 4;60(RR-3):1–18.
- Kirking HL, Cortes J, Burrer S, Hall AJ, Cohen NJ, Lipman H, et al. Likely transmission of norovirus on an airplane, October 2008. Clin Infect Dis. 2010 May 1;50(9):1216–21.
- Koo HL, Ajami NJ, Jiang ZD, Neill FH, Atmar RL, Ericsson CD, et al. Noroviruses as a cause of diarrhea in travelers to Guatemala, India, and Mexico. J Clin Microbiol. 2010 May;48(5):1673–6.
- Patel MM, Widdowson MA, Glass RI, Akazawa K, Vinje J, Parashar UD. Systematic literature review of role of noroviruses in sporadic gastroenteritis. Emerg Infect Dis. 2008 Aug;14(8):1224–31.
- Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, et al. Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011 Jan;17(1):7–15.
- Thornley CN, Emslie NA, Sprott TW, Greening GE, Rapana JP. Recurring norovirus transmission on an airplane. Clin Infect Dis. 2011 Sep;53(6):515–20.
- Widdowson MA, Cramer EH, Hadley L, Bresee JS, Beard RS, Bulens SN, et al. Outbreaks of acute gastroenteritis on cruise ships and on land: identification of a predominant circulating strain of norovirus—United States, 2002. J Infect Dis. 2004 Jul 1;190(1):27–36.
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